Are epinephrine (adrenaline) and antiarrhythmics recommended in traumatic cardiopulmonary arrest?

From the Guidelines

Epinephrine and antiarrhythmics are not the primary interventions in traumatic cardiopulmonary arrest, and their use should be considered only after addressing the underlying causes of the arrest. The management of traumatic cardiopulmonary arrest should focus on identifying and treating the reversible causes of the arrest, such as hypovolemia, hypoxia, tension pneumothorax, and cardiac tamponade, using the "H's and T's" approach 1.

Key Considerations

• The use of epinephrine in traumatic cardiopulmonary arrest is not a priority intervention, and its administration should be considered only in later stages of resuscitation, after addressing the reversible causes of the arrest 1.
• Antiarrhythmic medications like amiodarone or lidocaine have limited value in traumatic cardiopulmonary arrest, as the cardiac rhythm disturbances are typically secondary to underlying causes such as hypovolemia, hypoxia, or tension pneumothorax, rather than primary electrical abnormalities 1.
• The priority in traumatic cardiopulmonary arrest should be rapid identification and treatment of the underlying causes, with particular attention to:
  • Hypovolemia: control external hemorrhage, fluid resuscitation
  • Hypoxia: ensure oxygenation
  • Tension pneumothorax: needle decompression
  • Cardiac tamponade: pericardiocentesis

Medication Use

• If epinephrine is used, the standard dose would be 1mg IV/IO every 3-5 minutes 1.
• Antiarrhythmic medications like amiodarone or lidocaine may be considered in specific cases, but their use should be guided by the underlying cause of the arrest and the patient's clinical condition 1.

Evidence-Based Practice

The recommendations are based on the most recent and highest-quality evidence available, including the 2022 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1, and the 2018 American Heart Association focused update on advanced cardiovascular life support use of antiarrhythmic drugs during and immediately after cardiac arrest 1.

From the Research

Epinephrine in Traumatic Cardiopulmonary Arrest

• The use of epinephrine in cardiac arrest has been a topic of debate, with some studies suggesting its effectiveness in improving return of spontaneous circulation (ROSC) 2, 3, 4.
• However, the evidence on its impact on long-term survival and neurological outcomes is conflicting 2, 3, 5, 6, 4.
• The American Heart Association recommends the use of epinephrine in patients with cardiac arrest, as part of Advanced Cardiac Life Support 2, 4.
• High-dose epinephrine is not recommended, as it may be harmful 2.
• The optimal dose and timing of epinephrine administration are still unclear, with some studies suggesting that lower doses may be effective 5 and earlier administration may improve outcomes 6.

Antiarrhythmics in Traumatic Cardiopulmonary Arrest

• There is limited evidence on the use of antiarrhythmics in traumatic cardiopulmonary arrest.
• The provided studies primarily focus on the use of epinephrine in cardiac arrest, with no direct mention of antiarrhythmics.

Recommendations

• The American Heart Association recommends epinephrine as part of Advanced Cardiac Life Support for patients with cardiac arrest 2, 4.
• However, the evidence on its effectiveness in traumatic cardiopulmonary arrest is limited, and more research is needed to determine the optimal treatment strategy 2, 3, 5, 6, 4.